6.5 Pressure Injury Prevention, Staging, and Treatment Scenarios
Key Takeaways
- Pressure injury scenarios combine risk assessment, skin inspection, support surfaces, repositioning, moisture control, nutrition, and documentation.
- Staging follows the 2016 NPIAP system and depends on visible tissue depth, not on wound size, drainage amount, or pain.
- Deep tissue pressure injury, unstageable pressure injury, and mucosal injury are common classification traps.
- The exam trap is focusing on the wound dressing while leaving pressure, shear, moisture, or device pressure uncorrected.
Pressure injury scenarios start with force
Pressure injury content spans several WCC domains: Assessment (skin integrity, wound status, risk tools, function, cognition, nutrition, pain, comorbidities), Treatment (support surfaces and wound treatments), and Risk and Prevention (impaired skin integrity and at-risk populations). The exam expects an integrated plan, not just a staging label.
A pressure injury is localized damage to skin and underlying soft tissue, usually over a bony prominence or under a medical device, from intense or prolonged pressure, often combined with shear (2016 NPIAP definition). Prevention begins by identifying immobility, sensory loss, moisture, poor nutrition, perfusion problems, devices, friction, sedation, and cognitive impairment. The Braden Scale quantifies risk across six subscales (sensory perception, moisture, activity, mobility, nutrition, friction/shear); lower totals mean higher risk, with 18 or below generally flagged as at risk and 9 or below at very high risk.
The 2016 NPIAP staging system
Staging changed in 2016: "injury" replaced "ulcer," Arabic numerals replaced Roman numerals, and the categories were clarified. Stage 1 is intact skin with localized non-blanchable erythema. Stage 2 is partial-thickness loss with exposed dermis, often an intact or ruptured serum-filled blister (no slough, no granulation). Stage 3 exposes adipose and may show slough, undermining, or tunneling. Stage 4 exposes or has palpable fascia, muscle, tendon, ligament, cartilage, or bone.
| Classification | Key exam cue | Common trap |
|---|---|---|
| Stage 1 | Intact skin, non-blanchable erythema | Calling it "not a wound" because skin is intact |
| Stage 2 | Partial-thickness loss; intact or ruptured serum blister | Mislabeling moisture-associated skin damage as pressure |
| Stage 3 | Full-thickness loss, adipose visible | Calling it Stage 2 because bone is not exposed |
| Stage 4 | Visible/palpable fascia, muscle, tendon, or bone | Staging by size instead of by depth |
| Unstageable | Full-thickness loss obscured by slough or eschar | Guessing a stage before the base is visible |
| Deep tissue pressure injury | Persistent non-blanchable deep red, maroon, or purple intact skin, or blood-filled blister | Waiting for skin to open before acting |
Medical-device-related and mucosal pressure injuries are separate: mucosal injuries (mouth, nares, urethra) are not assigned a numeric stage because mucosal tissue histology differs from skin.
Worked scenario, treatment, and traps
Applied scenario: a bedbound patient has a dark purple, intact, painful heel. The best answer is not to massage it or wait until it opens. Offload the heel (float heels off the bed with a pillow under the calf or a heel-suspension device), assess perfusion, protect the skin, notify per policy, document the discoloration as a deep tissue pressure injury if criteria fit, review the support surface and turning plan, and monitor for evolution, since deep tissue injuries can deteriorate rapidly.
Staging is never based on wound size, drainage, infection, or pain; a small Stage 4 can be deeper than a large Stage 2. Treatment must always address pressure and shear: scheduled repositioning (commonly every 2 hours in bed and hourly when seated, individualized), an appropriate support surface, heel offloading, transfer technique, keeping the head of bed at or below 30 degrees when tolerated to limit shear, moisture/incontinence management, a nutrition referral (protein and calorie support, hydration), and pain control. A sacral foam dressing may protect skin but does not fix a patient sliding down in bed.
Device-related pressure is a recurring trap: oxygen tubing, masks, cervical collars, casts, splints, compression wraps, tubing, and footwear all injure tissue. Inspect under and around every device and pad or reposition per policy. Final traps: do not massage reddened skin (it can worsen deep injury) and do not use donut/ring cushions (they concentrate pressure). Never "reverse stage" a healing wound; a healing Stage 4 is described as a healing Stage 4, not a Stage 2.
Support-surface selection and the blanch test
Support surfaces are matched to risk and mobility. Reactive surfaces (static foam, gel overlays) suit patients who can reposition independently and remain at moderate risk. Active/alternating-pressure mattresses cyclically shift load and suit high-risk, immobile patients or those with existing injuries who cannot offload a surface. The key exam principle is that a specialty surface supplements turning -- it never replaces it.
A practical bedside skill is the blanch test: press a reddened area; if it blanches (whitens then refills), it is likely Stage-1-pending or reactive hyperemia, whereas non-blanchable erythema confirms Stage 1 tissue damage. This is the line the exam draws between transient pressure response and a true injury.
Moisture, nutrition, and distinguishing MASD
A frequent classification trap is confusing moisture-associated skin damage (MASD), such as incontinence-associated dermatitis, with a pressure injury. MASD is typically diffuse, in skin folds or the perineum, with irregular borders and no relation to a bony prominence, and it is managed with a structured skin-care regimen: gentle cleansing, a moisturizer, and a moisture barrier or breathable absorbent product. Pressure injuries, by contrast, localize over bony prominences and follow the pressure-and-shear pattern.
Nutrition is a named prevention pillar: identify malnutrition risk, ensure adequate protein, calories, and fluids, and trigger a dietitian referral, because no support surface or dressing closes a wound in a protein-depleted patient. Tie every plan to the patient's goals -- a comfort-focused patient may decline aggressive turning, and honoring that documented choice is appropriate care, not neglect.
An intact heel shows persistent non-blanchable purple discoloration and pain after prolonged immobility. What is the best WCC response?
A full-thickness pressure injury is completely covered by eschar, so the base cannot be seen. How should it be classified under the 2016 NPIAP system?
Which repositioning and dressing combination best reflects pressure injury cause control for a patient sliding down in bed?